Summary: Mr X complained for his father, Mr Y, about the standard of care at the Grange Nursing Home (the Grange) and the Council’s decision to end one to one support. The Ombudsman did not find fault in the Council’s decision to stop one to one support or in the care provided by the Grange. There was some fault in the Council’s record keeping.

The complaint

1. Mr X complained for his father, Mr Y, about the standard of care at the Grange Nursing Home (the Grange) and at the Council’s assessment Mr Y no longer needed one to one support.
2. Mr X suffered distress and was put to time and trouble trying to get care in place for Mr Y. He would like Mr Y moved to a different care home, able to meet his needs.

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The Ombudsman’s role and powers

3. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word ‘fault’ to refer to these. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
4. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

5. As part of the investigation I have considered the following:
• The complaint and the documents provided by the complainant’s representative.
• Documents provided by the Council and its comments in response to my enquiries.
• The Care Act 2014.
6. Mr X and the Council both had an opportunity to comment on a draft of this decision.

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What I found

7. The Care Act 2014 sets out the legal framework for adult social care. Councils must assess any adult that appears to have needs for care and support.
8. The Department for Health issues statutory guidance on the Care Act 2014 that we expect councils to follow.
9. The purpose of a care assessment is to identify a person’s needs and how these needs impact on their well-being. The care assessment must take account of the results someone wishes to achieve in their day-to-day life and support them to have choice and control. The assessment will inform the decision on whether any needs identified are eligible for care and support from the council.
10. If the council decides someone has eligible needs, it must complete a care and support plan setting out how it will meet those needs. There are different ways a council can meet someone’s needs. The council does not have to provide a funded service.
11. Ealing Borough Council’s adult social care service has a high needs panel, chaired by the Assistant Head of Service. It approves decisions about how the Council will meet someone’s needs and agrees to the costs of the service provided.
12. Statutory Guidance requires councils to review care and support plans at least every year, on request or in response to a change in circumstances. (Care and Support Statutory Guidance, Paragraph 13.32)
13. The Mental Capacity Act 2005 sets out the principles for working with people who lack capacity to make a decision. The five key principles in the Act are:
• every adult has the right to make his or her own decisions and must be assumed to have capacity to make them unless it is proved otherwise.
• a person must be given all practicable help before anyone treats them as not being able to make their own decisions.
• just because an individual makes what might be seen as an unwise decision, they should not be treated as lacking capacity to make that decision.
• anything done or any decision made on behalf of a person who lacks capacity must be done in their best interests.
• anything done for or on behalf of a person who lacks capacity should be the least restrictive of their basic rights and freedoms.

What happened

14. Mr Y suffers from dementia and has difficulty with thinking, concentration and other functions. He is still active and likes to walk. He went into a nursing home in July 2012. He fell and broke his hip in February 2017 and was hospitalised while he recovered.
15. In April 2017, the NHS confirmed Mr Y did not meet the criteria for continuing healthcare. However, he was eligible for funded nursing care. The NHS assessed Mr Y as having high needs with cognition, communication and drug therapies and medication. It said his behavioural needs were moderate.
16. Mr Y received rehabilitation from June 2018 until December 2018, when he moved to the Grange.
17. The Council’s senior practitioner in adult services stressed it needed to agree funding for one to one supervision as without this a home would not accept Mr Y because of the risk of falls or absconding. Following a meeting with the assistant head of service, the Council decided Mr Y would have one to one supervision for 12 hours a day. It would review this each month. The Council told Mr X of its decision and that it would be keep his care under review.
18. Mr X wanted Mr Y moved to another care home, Maryville. The Council found out Maryville had no vacancies and the cost of care was more expensive, meaning Mr X would have to pay a top up fee. Mr X would not pay the top up fee. The only home with vacancies able to give one to one support was the Grange.
19. Mr Y’s care notes for January 2018 confirm staff provided one to one care during the day, and at night a member of staff sat next to Mr Y’s door. He was eating and drinking and keeping up with personal hygiene. He needed much help with this but was reported to be happy and content.
20. There is a record of challenging behaviour on 23 January 2018 where Mr Y hurt others and where another resident threw chocolate at Mr Y for moving about near the television.
21. The Council reviewed Mr Y’s needs on 1 February 2018. The assessment confirmed Mr Y still needed one to one supervision to allow him to settle into the care home and new environment. The Council would review this in another two to three weeks.
22. On 17 April 2018 the Council’s high needs panel agreed to extend one to one supervision for another four weeks. However, the panel asked for evidence of what one to one support the Grange provide and how it was using time effectively.
23. The Council contacted the Grange and asked for a support plan showing how the home managed Mr Y’s needs.
24. The Grange said one to one care was not their choice, but was allocated for Mr Y’s safety, and because Mr X raised concerns. The Council ended one to one supervision on 11 June 2018.
25. The Council contacted the Grange on 16 June 2018 to follow up after it ended one to one supervision. The Grange said Mr Y was cooperating with his care. There were no concerns and it did not notice a difference since one to one supervision ended.
26. Mr X reported concerns to the police on 4 July 2018 about Mr Y’s care. He said Mr Y suffered cuts to his arms and face on 11 June 2018 and staff at the Grange did not know how.
27. The Council received the police report on 11 July and contacted the Grange on 12 July. The Grange said Mr X had been unhappy since one to one support ended and blamed staff at the home, for saying they could manage. It confirmed there had been no further incidents. Mr Y is at high risk of falling because of his condition, but this can happen even if supervised.
28. A safeguarding strategy meeting took place on 31 July 2018. Mr X asked the Council to reinstate one to one supervision. He said Mr Y was injured because he is wandering into other residents’ rooms and being assaulted. He said the injuries were not the result of a fall. The Grange said it could care for Mr Y without one to one support. It said it was not possible to remove all risks even with one to one support.
29. Mr Y suffered a cut to his forehead on 12 February 2019. Staff at the Grange believed Mr Y tripped and banged his head on the bed of another resident after wandering into their room. Carers were serving breakfast and one went out straight away to follow Mr Y and found him on his knees.
30. The Council spoke to Mr X after he raised a safeguarding concern. He was unhappy with the care at the Grange because Mr Y had several accidents. He thought Mr Y had been assaulted.
31. The Grange contacted the Council on 8 March 2019 after Mr Y had another fall, in the lounge of the home. The Grange called an ambulance, but it did not attend as the incident was not serious enough. The Council told the Grange to call a doctor and put a protection plan in place. It said management would discuss the case and consider if Mr Y needed one to one supervision again.
32. Mr X made a safeguarding complaint on 14 March 2019 after Mr Y had another fall on 13 March. He said Mr Y suffered repeated violence at the Grange because of withdrawing one to one support.
33. The Grange contacted the Council on 19 March 2019 and asked it to consider reintroducing one to one support. A doctor examined Mr Y and said he needed increased supervision because of the number of falls. The doctor did not think a falls clinic would help because Mr Y could not engage.
34. The Council carried out a review and assessment on 9 April 2019. The social worker who assessed Mr Y said the high needs panel should consider whether the Council could reinstate one to one support.
35. Mr Y’s care and support plan, dated 11 April 2019, states all his needs must be anticipated. Carers manage his medication and he can eat and drink independently. Staff must support Mr Y to walk safely. He needs constant supervision to prevent the risk of falls. To minimise the risk of Mr Y wandering into other resident’s rooms he sits with staff to watch television and staff take him for walks around the building. The Council cancelled one to one supervision because the Grange confirmed it can meet Mr Y’s needs without extra supervision.
36. The social worker who assessed Mr Y left the Council on 17 April 2019.
37. The Ealing Centre for Independent Living (ECIL) sent an email to the Council to complain on Mr X’s behalf on 20 June 2019. It referred to falls and injuries suffered by Mr Y at the Grange and asked the Council to reinstate one to one support. It also asked the Council to explore a move to a different care home.
38. The Council responded on 24 June 2019. It said many of the issues raised occurred almost a year ago and are not current concerns. Mr Y’s falls prompted a reassessment on 22 March 2019. The Council found Mr Y’s falls were isolated incidents and there had been no further instances. There were no concerns about his placement at the Grange and no need for one to one supervision. The Council said it does not provide long term one to one support and this would not prevent Mr Y from falling. It said Mr Y’s social worker will speak with the home and, if necessary, hold another review.
39. The Council contacted the Grange on 25 June 2019. The Grange reported no changes, incidents or falls since the last review in March. Mr Y was mobilising actively around the home and the Council did not consider there was a need to review the existing arrangements.
40. The Council sent a further email to ECIL on 1 July 2019. It confirmed a social worker spoke with the Grange and there was no need for one to one support or extra care.
41. ECIL emailed the Council again on 4 July 2019. It said there was conflict in accounts, because the Grange told Mr X that Mr Y was assaulted but told the Council there have been falls. It asked why the Council had not mentioned the police reports. It again asked for Mr Y to move to another home where he will not need one to one support because the staff to patient ratio is higher.
42. The Council replied on 5 July 2019. It said staff to resident ratios are no longer used. Homes have different staffing levels based on the needs of residents. The Grange said the issue of Mr Y wandering into other residents’ rooms was not a problem. The Council said it must separate what happened in the past from current issues. It agreed to hold another review and then consider a move, but said the need would have to be great, considering Mr Y’s age and condition.
43. The Council contacted the Grange on 11 July 2019 for an update. The Grange reported Mr Y was settled and had not had any falls since March. He does wander but staff manage this well and there are no concerns about his care.
44. Mr X brought his complaint to the Ombudsman on 25 September 2019. He said Mr Y suffered repeated injuries and assaults at the Grange. The Grange could prevent Mr Y from suffering injuries while one to one support was in place, but he was injured again as soon as one to one support stopped.

Response to my enquiries

45. The Council told me it did not refer the matter to its high needs panel after the re-assessment in April 2019. Instead it decided to continue to monitor Mr Y. He only had two falls since one to one care ended in June 2018 and the Grange did not report any further concerns. It was not clear Mr Y needs one to one support.
46. The Council contacted the Grange on 25 June 2019 and the home said there had been no change in Mr Y’s behaviour since March 2019 and no more falls. While Mr Y still entered other resident’s rooms at times staff could manage this.
47. The Council confirmed a new social worker took over Mr Y’s care on 5 July 2019 and carried out a reassessment. There was no evidence Mr Y needed one to one support. Mr Y had settled at the Grange and had no further falls. The Council will review Mr Y’s placement routinely. 

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Analysis

48. Mr X only wants what is best for his father. I recognise he does not consider the Grange can keep Mr Y safe without one to one support being in place. However, the Ombudsman cannot assume the Council’s decision-making role. It is not enough for Mr X to disagree with the Council, I must find fault in its decision.
49. The Council and the Grange, acting on its behalf, cannot remove all risks posed by Mr Y’s condition. I am satisfied the Grange and the Council responded properly as events unfolded and when Mr Y suffered injuries.
50. I consider the Grange had due regard to Mr Y’s needs. Mr Y has a progressive condition which is likely to decline naturally irrespective of his care arrangements.
51. The care and support plans aimed to minimise the risks posed by Mr Y’s dementia by putting in place tailored care to meet his needs. The social workers considered the wishes of Mr X, as well as the views of the Grange and Mr Y’s doctor. The Council undertook regular reviews of Mr Y’s care needs, both periodically and in response to requests from Mr X. While I accept Mr X felt the risk of Mr Y suffering harm was unacceptable, I do not consider there was any fault in the approach taken by the Council. Its care planning tried to minimise risk, it could not remove it.
52. One to one support was not intended to be permanent. The Council told Mr X this before Mr Y went into the Grange. Its decision to remove one to one support was a considered one, taking account of relevant information, and I do not find fault with it. There is a difference of opinion about whether Mr Y still needs one to one support. Mr X disagrees with the Council, but I have not seen evidence of fault in the Council’s decision making so I have not questioned the merits of its decision.
53. Following Mr Y’s falls in March 2019, his social worker recommended the Council’s high needs panel consider one to one support again. This did not happen. The Council told me its management staff decided to monitor the situation. However, Mr Y’s care records are silent on the issue. That was fault. I would expect the records to detail why the Council thought it suitable to monitor Mr Y and not act straight away on the need for one to one care identified by the GP and in the social worker’s assessment.
54. I do not consider the fault caused any injustice. This is because the Council remained in contact with the Grange. It sought updates on Mr Y’s care, and a social worker carried out a further review in July 2019. On the back of the findings of the review, and the views of the Grange, the Council was entitled to decide it did not need to change Mr Y’s support.

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Final decision

55. I have completed my investigation. The Ombudsman did not find fault in the Council’s decision to stop one to one support or in the care provided by the Grange. There was some fault in the Council’s record keeping.

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Investigator's decision on behalf of the Ombudsman